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Soft tissue removal?

  1. Default Soft tissue removal?
    Medical Coding Books
    Hello everyone,

    I'm having trouble with the following op report. Not sure what CPT code to use, soft tissue CPT, integumentary 114xx or 17110? It doesn't even document the size properly.

    DX: Multiple soft tissue neoplasms of right foot, greater than 20. Path report states: Verruca

    53 yr old presented to ASC for soft tissue neoplasms of the right foot, numbering greater than 20, consistent in appearance to verruca plantaris.

    Attention was then directed to the patient's right plantar heel, where the largest neoplasm was identified, and two converging semi elliptical incisions were amde encompassing the central lesion. The incision was approximately 3cm length and 1cm in width. The skin wedge was then ellipsed out to the level of fat and removed from the surgical field in toto, and sent off to pathology. Next a similar technique was used for three lesions proximal to the central lesion, as well as one lesion distal to it. These two were excised down to the level of fat and removed from the surgical field in toto, and also sent off for pathology.

    At this time, several other small lesions were noted and were cauterized. All sites were then cauteriaed, curetted, cauterized again, and the curetted again. The areas that were excised were reapproximated using 4-0 nylon. the wounds were dressed in bacitracin, adaptic, sterile gauze, kerlix and an Ace bandage.


  2. #2
    Piedmont Area Coders, VA
    Good Question.
    CPT prompts us to use the 17110 codes.. The "Coding Guidance" listed in the CPT expert edition, includes the word "excision", whereas the actual language of the 17110 does not. I think you are kinda stuck using these codes, 17110-17111, based on your total number of lesions removed.

    Thoughts from anyone else?!?!

  3. Default
    I would agree with the 17110-17111. This is what I would bill if it were my providers

    Kelsey, CPC

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